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AUTHORIZATION TO DISCLOSE INFORMATION

DHB- 5028 (02/2020). WHOSE Records to be Disclosed: NORTH CAROLINA First Middle Last NAME: DIVISION OF HEALTH BENEFITS. Birthday mm/dd/yy SSN: -------------------------- COUNTY. DEPARTMENT OF SOCIAL. ADDRESS: SERVICES. AUTHORIZATION TO DISCLOSE INFORMATION . I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange): OF WHAT: All my medical records; also education records and other INFORMATION related to my ability to perform tasks. This includes specific permission to release: 1. All records and other INFORMATION regarding my treatment, hospitalization, and outpatient care for my impairment(s). including, and not limited to: -- Psychological, psychiatric or other mental impairment(s) (excludes "psychotherapy notes" as defined in 45 CFR ). -- Drug abuse, alcoholism, or other substance abuse -- Sickle cell anemia -- Human immunodeficiency virus (HIV) infection (including acquired immunodeficiency syndrome (AIDS) or tests for HIV) or sexually transmitted diseases -- Gene-related impairments (including genetic test results).

Federal law permits sources with information about you , to release that information if you sign a single authorization to release all your information from all your possible sources. We will make copies of it for each source. A covered entity (that …

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Services Information System - Policies and Manuals

policies.ncdhhs.gov

DSS-5010, Social Services Application, Eligibility Documentation, and Notice • DSS-1360, Purchase of Services: Referral and Authorization . Policy governing the requirements for the use of the DSS-5027 can be found in the Requirements for the Provision of Services by County Departments of Social Services at:

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C. Department of Juvenile Justice and Delinquency N.C.G.S. § 7B-3100 and 28 NCAC 01A .0301 state that the Department of Juvenile Justice and Delinquency Prevention shall designate local agencies that are authorized to share information concerning juveniles. Agencies so designated shall share with one another,

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policies.ncdhhs.gov

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policies.ncdhhs.gov

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policies.ncdhhs.gov

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policies.ncdhhs.gov

resulting from the abuse or neglect of a child(ren). • A request from an out-of-state DSS (public child welfare agency) with a juvenile court case (including permanency planning or termination of parental rights (TPR)) resulting from the abuse or neglect of a child(ren).

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I understand that this authorization will expire 60 days after I have signed the form. 2. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations.

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